Clinical paperImplementation of a standardised treatment protocol for post resuscitation care after out-of-hospital cardiac arrest☆
Introduction
Despite science based guidelines for cardiopulmonary resuscitation (CPR),1 the survival rate after out-of-hospital cardiac arrest (OHCA) has not improved much over the last decade.1, 2 The guidelines focus mainly on treatment until return of spontaneous circulation (ROSC), due to scarcity of studies on the post resuscitation period.1 Therapeutic hypothermia is reported to improve survival and neurological outcome in patients with ventricular fibrillation.3, 4 Two non-intervention cohort studies reported significant inter-hospital differences in survival (for those admitted with ROSC) that could not be explained by pre-hospital factors.5, 6 In-hospital body temperature, seizures, blood glucose and base excess were related to outcome.6
In Oslo, survival of those admitted to the intensive care unit (ICU) with ROSC has stayed at 25–35%,6, 7, 8 similar to the 30% reported in 22,105 patients in UK,9 but lower than the 56% reported in Stavanger,6 with the best reported survival rate in Europe.10
Based on the assumption that in-hospital factors could be important, we designed a standardised treatment protocol including therapeutic hypothermia, percutaneous coronary intervention (PCI) – if indicated – and standardised goals for factors such as blood glucose, haemodynamics, ventilation and handling of seizures. With focus on better care and improved survival for OHCA patients admitted to hospital, this was implemented into our hospital system. Since it was a multivariate systems approach, patients could not be randomised to either receive the required treatment or not in the emergency department (ED) and intensive care unit (ICU). The results were therefore compared to patients admitted to Ulleval University Hospital (Ulleval) in a recently published study from the preceding period.6
Section snippets
Patients and methods
The Norwegian Board of Health, Norwegian Social Science Data Service and Regional Committee for Medical Research Ethics approved the study.
Patients admitted to Ulleval ICU
During the 20.5 months intervention period 61 patients with OHCA of cardiac aetiology were admitted to ICU with ROSC versus 58 in the 24 months control period (Figure 1). All survivors with a favourable neurological outcome in both groups were still alive 1-year after discharge (Figure 1, Table 1).
Significantly more patients survived with a favourable outcome in the intervention period compared to the control period; 34 of 61 (56%) versus 15 of 58 (26%), p < 0.001 (Table 2). Mean age (63 ± 14
Discussion
The 56% survival to hospital discharge with favourable neurological outcome and 1-year survival among OHCA patients admitted to ICU is high compared to our previous results6, 7, 8 and those results reported from other institutions.5, 9, 13, 14, 15, 16 The value of the CPC score on hospital discharge as an indicator of quality of life and cognitive function later in life has been questioned,17 but is still the standard evaluation tool recommended in the last ILCOR scientific statement for
Conclusions
Survival to hospital discharge with good neurological recovery, and 1-year survival, in patients admitted to the ICU after OHCA of cardiac aetiology, improved after implementation of a standardised post resuscitation care treatment protocol in our hospital. This protocol included therapeutic hypothermia, PCI, and a focus on goal-directed treatment for the reperfusion period. Due to the study design a cause-and-effect relationship cannot be firmly established, but the results are encouraging.
Conflicts of interest disclosures
Dr. Sunde has received research grants from Laerdal Foundation for Acute Medicine and Professor Steen is a member of the Board of Laerdal Medical.
Acknowledgments
We are greatly indebted to MSc Mitchell Loeb (Sintef, Health Research, Oslo) for skilful help with the statistical analyses. This study was supported by grants from Laerdal Foundation for Acute Medicine, Ulleval University Hospital Scientific Advisory Council and Health Region East.
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A Spanish translated version of the summary of this article appears as Appendix in the final online version at 10.1016/j.resuscitation.2006.08.016.